Right on time…. Apologies for delay everyone, holidays put a spell on the audio equipment, it seems. Audio is now posted!
-Imaging foreign bodies: Everything you’ve ever wanted to know
-Chest CT occult traumatic injury findings, a study
-Low risk chest pain scoring systems: how do they stack up in one cohort?
-ED a Fib management and quality of life: FINALLY, a study that asks the right question!!!
-30 day mortality after A fib management in the ED: deriving a risk score
And lots lots more. Check it out, January coming soon….
Report from the Section Council on Emergency Medicine: Highlights of the AMA Interim Meeting, Nov 2015, Atlanta, GA
515 of 540 Delegates sat for debate on the Monday opening of the House of Delegates (HOD). We were fresh off a Capitol Club luncheon starring a PBS anchor and Fox News reporter about the current state of Presidential Campaigning. Fascinating but impossible to predict seems the result as all known rules don’t seem to apply.
We typically have a 30-minute opening session of the HOD on Sunday morning. Instead, 90 minutes later the House recessed to reference committees after a lengthy exercise in parliamentary procedure referable to a new rule on “A motion to table” which is not debatable. The AMA recently changed its parliamentary resource from Sturgis to the American Institute of Parliamentarians Standard Code of Parliamentary Procedure. With the addition of this rule, it was used to prevent debate on a subject that the HOD did not seem to want to spend time discussing, namely issues related to Planned Parenthood. Arguments ensued about denial of opportunity for a minority to be heard. The House voted about 350 to 109 to table. Part of this plurality was due to the issue and part probably due to angst against the physician who brought the issue, having brought similar issues to the HOD repetitively in the past.
A special reference committee on the Modernized Code of Medical Ethics heard testimony on the latest Council on Ethical and Judicial Affairs (CEJA) effort to modernize the code. The code was again referred back for further work based on numerous objections. An example is the Code does not allow a physician to participate in assisted suicide. However many states have laws that allow physicians to do so. California law apparently stipulates that the state law will trump the AMA Code of Ethics. But many states do not have this protection.
Unanimous testimony was offered in support of the medical student resolution to remove disincentives and study the use of incentives to increase the national organ donor pool. Misery and disability due to lack of organs is evidenced every day in our practices. The HOD voted first to support a study on use of incentives, including valuable consideration, second to eliminate disincentives and third to remove legal barriers to research investigating the use of incentives.
The HOD voted to support seeking over the counter approval from the FDA for Naloxone and to study ways to expand the access and use of naloxone to prevent opioid-related overdose deaths.
There were resolutions that touched on balance billing and network adequacy as it relates to emergency services. One was reaffirmed as previous AMA policy endorsing fair payment for emergency care. Another was adopted directing the AMA to advocate that health plans be required to document to regulators that they meet requisite standards of network adequacy, including for hospital-based physician specialties at in-network facilities and supporting that insurers pay out-of-network physicians fairly and equitably for emergency and out-of-network bills in a hospital.
There were again multiple resolutions regarding MOC which were referred to the Board for ongoing action reflecting the productive dialogue between ABMS and the AMA/Council on Medical Education. GME was again highlighted as an urgent need for action to expand GME positions to better match the expansion of medical school graduates.
Medical students proposed multiple resolutions regarding the need to address wellness throughout the medical education/practice environment.
As usual, several educational sessions were also held at the AMA. The AMA website summarizes several of those sessions, including:
- “5 things every modern medical practice needs”
- “Physicians reaffirm commitment to stop insurance mergers”
- “Attend to EHRs so we can attend to patients, physicians say”
- “CDC panel shares solutions to combat antibiotic resistance”
- “New program helps develop the skill set every physician needs”
- “Get published using these 5 writing and research tips”
Highlights of the opening session were two. First was a presentation by President Steve Stack to Cal Chaney, an executive recognition award for his outstanding contributions to the AMA and ACEP during his many years as staff of the Section Council on Emergency Medicine. Second was of course an outstanding address by our AMA President, Steve Stack, a speech interrupted numerous times by thunderous applause. The Board of Trustees members are uniformly complimentary and appreciative of Steve’s service on the Board and his performance as President. We are justly proud of him and having an emergency physician as President of the AMA. You can see a synopsis of his speech and hear it at the following link:
ACEP and EMRA were also proud to host a reception for medical students attending the Interim Meeting to mingle and discuss careers in emergency medicine with the medical students. In addition to ACEP’s five delegates and five alternate delegates, the EM footprint in the HOD continues to grow and flourish. 21 emergency physicians serve as HOD delegates or alternate delegates for their state societies. Several others serve in key positions on various councils and sections. Among those emergency physicians, other interested physicians, medical students and ACEP staff attending one or both of the Section Council on Emergency Medicine meetings were:
Nancy J. Auer, MD, FACEP
Mark Bair, MD
Michael D. Bishop, MD, FACEP
Brooks F. Bock, MD, FACEP
Michael L. Carius, MD, FACEP
Ted Christopher, MD
John Corker, MD
Shamie Das, MD, MPH, MBA
Erick Eiting, MD
Stephen K. Epstein, MD, MPP, FACEP
Hilary Fairbrother, MD, MPH
Catherine Ferguson, MD
Gary Figge, MD
Diana Fite, MD, FACEP
Wayne Hardwick, MD
Marilyn Heine, MD, FACEP
David Hexter, MD, FACEP
Rebecca Hierholzer MD
Amy Ho, MD
Tiffany Jackson, MD
Jay Kaplan, MD, FACEP
Gary Katz, MD
Seth M. Kelly
Marc Mendelsohn, MD
John C. Moorhead, MD, MS, FACEP
Joshua B. Moskovitz, MD, MPH, FACEP
Richard Nelson, MD
Reid Orth, MD, PhD, MPH
Rebecca B Parker, MD, FACEP
Craig Price, CAE
Alexander M. Rosenau, DO, CPE, FACEP
Matthew Rudy, MD
Sarah Selby, DO
Michael J. Sexton, MD, FACEP
Steven Stack, MD, FACEP
Richard L. Stennes, MD, MBA, FACEP
Ellana Stinson, MD
Arlo Weltge, MD
Jennifer Wiler, MD, MBA, FACEP
Dean Wilkerson, JD, MBA, CAE
Joseph P. Wood, MD, JD, FACEP, FAAEM
Carlos Zapata, MD
Posted! Highlights include:
-Identifying barriers to detecting child abuse
-Cost advantages of the ‘Low Risk Ankle Rule’
-Crowding in the ED, associations with outcomes after discharge
-Jet injector for venipuncture pain in kids
-Everything you wanted to know about how the ACA affects EM
-Vent management 101 – back to basics
And way more, as always.
Reach out any time, we’d love to hear from you,
Once again, the podcast/audio is full of good stuff.
-ED prescriptions for warfarin and long term use: remarkable adherence benefits?
-Nitrates in aortic stenosis — another myth busted?
-Review of d-dimer for detecting aortic dissection
-Steroids in anaphylaxis: not helping?
-Cricothyrotomy in the recently deceased
-Caring better for LGBT patients
And more, more, more.
Let us know what you think, email any time, and enjoy ACEP 2015!
September Annals Audio is posted here, check it out:
-Ketamine v morphine for pain
-Is droperidol safe for agitation… the unsurprising answer
-Opiates in the ED: 1) the patient perspective, 2) ED prescribing patterns
-Contrast-induced kidney injury, and one year outcomes
-Ebola triage and decision aid, transport of Ebola patients, and ED Ebola processes
and, as always, much much more.
Until next time, email any time at email@example.com,
The August episode of the Annals Audio/Podcast is now available here. Highlights include:
-Color coding pediatric resuscitation syringes: a new (i.e. better) way
-Oral contrast in peds abdominal trauma: worthwhile or worthless?
-Antibiotics only for peds appendicitis: the literature
-Vital signs at handoff — “Forgot to mention: he’s hypotensive…”
-H Pylori testing in the ED
-Tackling smoking in the ED, a RCT: it worked
-QT prolongation in antipsychotic overdose: less common than we thought?
Check it out and email anytime at firstname.lastname@example.org!
July podcast/audio is now posted, check it out. Highlights:
-Self-care barriers for CHF patients: are most ED visits inevitable?
-Communication between doctor and patient surrounding ACS admissions: there isn’t much…
-Is the Golden Hour still golden?
-Boston bombings: preventing future IT problems that affected response
-HIV ‘care continuum': is it being respected in the ED?
And much much more. Email any time at email@example.com,
Posted and available, right here. Highlights:
-Children who bounce back with meningitis or sepsis: a review
-Rapid administration of ketamine, quick-on/quick-off?
-ED use among patient-centered medical home participants
-ED use among young adults after the Affordable Care Act
-Intercepting wrong-patients orders in a CPOE system
Plus snapshot reviews, a game changing Steve Green editorial, and more….
Email any time at firstname.lastname@example.org,
By Walter L. Green, MD, FACEP
UTSW, Dallas, Texas
Dr. Smith sees a 23-year-old male with a right hand injury. The patient was at a bar last night and hit another patron in the mouth. He has pain at the right 5th metacarpal phalangeal (MCP) joint and a small laceration. History is otherwise negative. Physical exam reveals a 1 cm laceration over the right 5th MCP, no surrounding redness or discharge, but the joint is tender with passive range of motion. Tetanus is updated and IV antibiotics given. X-ray shows a boxer’s fracture with displacement and no foreign body. Orthopedics is consulted.
Dr. Smith records a diagnosis of “fight bite.” Orthopedics decides to take the patient to the operating room for irrigation of the wound and repair of the open fracture.
The transition to ICD-10 will occur on 10-1-15. ICD-10 requires a higher degree of specificity to correctly code orthopedic and hand injures. In this example, it would be important to document where and how the injury occurred and whether alcohol was a contributing factor. The precise location of the fracture, including which hand, which finger, and which phalange are all needed for accurate coding of the encounter.
In this example, it would be better for the ED physician to diagnose “open, displaced fracture of right 5th metacarpal bone.”
The ED coder would assign the following ICD-10 diagnosis codes:
S62.336B (Displaced fracture of the neck of fifth metacarpal bone, right hand, initial visit for open fracture)
S61.451A (Open bite of right hand, initial encounter) to describe the mechanism of injury.
For the Evaluation & Management service, the coder would also assign a CPT code such as 99284.
For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page at http://www.acep.org/content.aspx?id=28754.
With passage of the Medicare Access and CHIP Reauthorization Act of 2015 it is official that ICD-10 CM will become a reality October 1st 2015. This is a huge deal for your billing company, hospital, payer contracts and you.
ICD-10 CM is an updated and expanded diagnosis coding system that will replace ICD-9.
At the very least, every clinician working in the ED will need to know how to document in an ICD-10 CM friendly manner. ICD-10 CM requires more specificity and details than ICD-9. Trauma and injuries make up a significant percentage of the new ICD-10 CM codes with laterality (left right upper and lower) now essential elements of the chart.
ICD-10 CM is ultimately tied to hospital and professional reimbursement; hence you also may be at risk for increased denials, charts deemed incomplete and an unhappy hospital CEO.
Here is a list of things you need to do now:
Identify your current systems and work processes that use ICD-9.
Diagnosis ICD coding is not just used for the final diagnoses, but is also used to justify ED testing such as CT scans, EKGs and lab tests. How does your current documentation system assign codes to diagnostics that you ordered? Although ED docs rarely order outpatient testing, be sure that your order form includes ICD-10 codes.
ED Professional Billing
Who is doing your professional billing? How are they going to implement ICD-10 CM? How are they conducting their internal and external validation testing?
Get to know your coder
Coder feedback will be critical. Try to develop a professional rapport with your coding staff such that they feel uninhibited to ask clarifying questions. Now might be a good time to buy the coding staff a large box of cookies.
ED Nurse documentation
Can you make your nurse triage note and nursing documentation more ICD-10 friendly? Consider prompts for external cause of injury, geographic location of injury and mechanism of injury. Documentation of laterality, left right and upper and lower now needs to be clearly documented.
Yes, once again physician productivity may go down. Perhaps your group is on the tipping point for the employment of scribes or extenders. ICD-10 may make such a decision more clear cut.
Randomly select 10-20 charts and ask your coders to code the charts via ICD-10 CM. This should provide a baseline to allow for individual provider education.
To help Emergency Physicians prepare for this change to ICD10, ACEP will be providing ICD-10 documentation tips and insights for the busy ED physician. You can find these resources in several locations, including:
ACEP’s monthly magazine, The Official Voice of Emergency Medicine, is planning articles in the months leading up to October 2015. Written by physicians, for physicians, news about ICD-10 will be specific to EM practice.
ACEP’s home page will include the latest updates, and an ongoing list of resources will be added to the Reimbursement section of the site. Currently, you can find clinical examples, an information paper and an ICD-10-CM manual.
EM Today Newsletter
ACEP partners with Bulletin Health Care to bring the latest health care news each morning from Monday through Friday. Included within EM Today is news and events specific to ACEP. Updates and links to the latest articles on ICD-10 will be included in this newsletter.
Each Saturday, a roundup of the week is delivered with ACEP partner, Multi-View. Also sprinkled throughout the newsletter are briefs specific to ACEP and emergency medicine. ICD-10 news will be included here.
ACEP has an active following on social media. Here are the outlets for information about ICD-10 to be disseminated through ACEP’s membership.